Diagnosis of pancreatitis masked by hyperlipemia. It is often difficult to confirm a diagnosis of acute pancreatitis in the presence of hyperlipemic serum because the serum amylase and lipase and the urinary amylase are frequently normal. We were able to substantiate the diagnosis of pancreatitis in seven patients with hypertriglyceridemia (greater than 1200 mg/100 ml) by the use of the simple amylase/creatinine clearance ratio and by the serial dilution of hyperlipemic serum. The amylase/creatinine clearance ration in the hyperlipemic pancreatitis patients (10.0%) was significantly (P GREATER THAN 0.001) higher than in normal patients (3.1%) and essentially the same as in nonlipemic pancreatitis patients (9.2%). The calculated serum amylase activity after serial dilution of the serum showed up to a tenfold increase in hyperlipemic pancreatitis, with no significant increase in normal controls, hyperlipemic controls, and nonlipemic pancreatitis.


Low blood pressure in young adults with cystic fibrosis: an effect of chronic salt loss in sweat? Young adults with cystic fibrosis have lower blood pressures than control subjects of similar age and sex. The low blood pressure may be related to the excessive loss of salt in the sweat of these patients. A beneficial effect of the cystic fibrosis gene may be protection against developing hypertension in both the homozygous and heterozygous states, especially if the heterozygote has borderline elevation of sweat electrolytes.


Guidelines for the management of hospitalized narcotics addicts. Opiate-dependent patients who are hospitalized for medical, surgical, or obstetrical reasons require proper management of their addiction to care of their presenting illness. Guidelines are offered for methadone support during hospitalization for the patient enrolled in a treatment program and for the street addict. The important clinical features of withdrawal reactions are outlined, and a method is presented for establishing an initial and supportive dose of methadone for street addicts. The use of analgesics in the addicted patient, the treatment of methadone overdose, and some problems in the management of mixed-drug abuse are discussed.


The community and medical education: organization and function of a board of concerned citizens. A Board of Concerned Citizens was organized in 1971 to facilitate the resolution of problems between the College of Medicne and Dentistry of New Jersey at Newark and the community in which it is located. The board has provided an orderly imput by consumers, representatives of community organizations and nonfaculty employees into decisions on policies and programs of the medical and dental schools. It has aided in the resolution of employee grievances and student problems, given support needed to assist the development of quality health care services, helped improve the climate for clinical research, and served as an intermediary between the community and college on issues of special concern to local residents. An opinion poll conducted 3 1/2 years after its organization shows c ontinued support by citizenry, nonfaculty employees, faculty, and students for a Board of Concerned Citizens. Experiences of the board indicate that investigations and recommendations of a properly organized and motivated group of community residents and leaders can provide an effective bridge between a community and a medical or dental school.


[New tetraene antibiotic, abkhazomycin]. The cultures of Act. L10-0740 and L10-0772 were isolated from a soil sample. By their morphological and cultural features they were close to Act. badiocolor and differed from the latter by their antibiotic properties. Because of this they were classified as a new variant of Act. badiocolor var. abhasus var. nov. The cultures produced a new tetraen antibiotic, named abkhazomycin. Its physico-chemical properties are presented.


[Effect of the aeration conditions on the biosynthesis of oxytetracycline and the formation of organic acids by a culture of Actinomyces rimosus]. The effect of the aeration conditions on oxytetracycline biosynthesis and production of organic acids by Act. rimosus was studied. Intensive biosynthesis of oxytetracycline in shaken flasks with concentrated complex media was observed at the rate of oxygen dissolution in the liquid ranging from 14 to 25 mg/1/min. Lower rates of the oxygen dissolution up to 7 mg/1/min resulted in decreased rates of the culture growth and the medium component consumption, decreased antibiotic levels, production of significant amounts of pyruvic and acetic acids.


[Determination of the filtration characteristics of the fermentation broths of antibiotic producers]. Main filtration characteristics of the fermentation broths are necessary for estimation of the filtration equipment, rational choice of the filtering apparatus, determination of the optimal conditions for their exploitation. In this connection studies were carried out with a purpose of determining the specific resistance and the content of the solid phase in the fermentation broths of the main antibiotics. It was shown that the above characteristics were closely connected with the biosynthetic conditions and medium composition. It was noted that the specific resistance of the precipitates of the fermentation broths of various antibiotic-producing organisms significantly differed, sometimes by several orders. Preliminary treatment of the fermentation broths before filtration provided a marked decrease in the resistance of the precipitate.


[Variability of the levorin producer, Actinomyces levoris Krass]. Natural variation of the levorin-producing organism Act. levoris, strain 28 was studied with respect to the colony morphology and production of levorin and levoristatin. The population of strain 28 consisted of 3 morphological colony types, the main type amounting to 99.7 percent. The strain variation with respect to production of levorin and levoristatin ranged from 20 to 180 and from 0 to 300 percent respectively as compared to the control. Mutant M-28 differing from the initial strain by the colony morphology, moderate phage titer and preferable production of levoristatin was isolated as a result of repeated passages of strain 28 onto agarized Chapek media with starch without maintaining selection. Variants differing from the population of strains 28 and M-28 by the ratio of levorin and levoristatin in the culture fluid were selected. No correlation in production of the above antibiotics by strain 28 was noted. Preparations obtained with strain M-28 differed from those obtained with strain 28 in a significant content of levoristatin.


False aneurysm as a late complication of anterior dislocation of the shoulder. A review of the leterature since 1947 fails to show a report of a false aneurysm with uncomplicated anterior shoulder dislocation. If this potential late complication is to be diagnosed and treated before the patient is released from followup medical care, careful attention must be given to alterations in the radial pulse prior to reduction. Patients who demonstrate an abnormal radial pulse which reverts to normal following reduction should have an angiogram. Pathological findings to the underlying axillary artery must be repaired promptly. Anterior dislocations of the shoulder account for approximately 50% of all dislocations and tend to be most frequent in healthy males. Late vascular complications associated with this injury are infrequent and can therefore be easily overlooked as illustrated in this report.


Sexual function after aorto-lliac surgery. Patients undergoing aorto-iliac operations frequently suffer severe physical and psychological problems as a consequence of postoperative sexual disability. In an attempt to reduce this symptom complex, careful preoperative and postoperative evaluations were performed on 20 patients undergoing such procedures. Their average age was 64 years. Patients were divided into groups distinguished by type of operative procedure and extent of sexual function, then carefully evaluated for changes related to technical aspects of the vascular reconstruction. Data were accumulated pertaining to preoperative and postoperative frequency of sexual intercouse, ability to achieve and maintain an erection, occurrence of retrograde ejaculation, and other symptoms of genitourinary dysfunction. Significant and disabling sexual dysfunction, found to occur after routine abdominal aneurysmectomy, aorto-femoral bypass grafting, and aorto-iliac endarterectomy, is believed to be related to type of operation and technical aspects of the procedure. The incidence of postoperative retrograde ejaculation and impotence was significant.


Inherited antithrombin-III deficiency causing mesenteric venous infarction: a new clinical entity. Primary superior mesenteric venous thrombosis is sometimes preceded by peripheral thrombophlebitis. Inherited antithrombin-III deficiency is a recently recognized autosomal dominant trait, which is characterized by thrombophlebitis and pulmonary embolism. This case report illustrates many features of both entities and strongly suggest a causal relationship. While long-term therapy has yet to be established, prophylactic therapy is recommended when asymptomatic individuals with known antithrombin-III deficiency are at increased risk of thrombosis. The efficacy of heparin alone has been unreliable, whereas Coumadin has been encouraging. Antithrombin-III concentrates are being developed and theoretically should be helpful. Patients with thrombophlebitis or pulmonary embolism should be suspected of having antithrombin-III deficiency. Such individuals also represent one mechanism to explain "primary" mesenteric venous thrombosis.


Results of ankle ststolic pressure measurements in patients with intermittent claudication being treated with clofibrate. Ankle systolic pressure measurements in 67 patients with intermittent claudication treated with Clofibrate for an average period of 11 months and 32 untreated patients suggest that 1) patients with a raised initial plasma fibrinogen concentration have more severe disease than those with low initial plasma fibrinogen concentration and 2) the response to treatment with Clofibrate is significantly better in those with a raised plasma fibrinogen concentration. On the basis of the patients own estimation of their claudication distance there was marked symptomatic inprovement in the treated patients. There was also a significant decrease in mean plasma fibrinogen levels in the treated patients and it is suggested that the hypofibrinogenemic effect of Clofibrate may be responsible for the benefit of this drug in patients with vascular disease.


Soft tissue sarcomas.

Soft tissue sarcomas. One hundred fifty-five adult patients with "operable" soft part sarcomas including rhabdomyosarcoma, liposarcoma, leiomyosarcoma and fibrosarcoma of the trunk and extremities are reviewed. Local recurrences of 93% and 60% occurred after local and wide excisions of the primary tumor. In this series of patients, amputation was the most efficient procedure for controlling the primary site. The absolute 5 and 10-year survival rates for all groups of tumors were 50% and 26%. Development of a second primary tumor of a different cell type occurred in 9% of the patients. Local recurrence, single distant metastasis, and/or second primary tumors should be considered potentially curable and appropriate surgical and/or radiation therapy carried out.


Influence of increased circulating levels of splanchnic lysosomal enzymes on the response to myocardial ischemia. The ability of increased circulating activities of lysosomal hydrolases to disrupt myocardial cellular membranes was studied in anesthetized cats. Increased activities of lysosomal hydrolases were achieved by splanchnic artery occlusion (SAO) shock or by infusion of liver extract (LE). Myocardial ischemia (MI) was produced by ligation of the left coronary artery. Coronary artery ligation resulted in sustained S-T segment elevation associated with significant increases in plasma creatine phosphokinase (CPK) activity within 5 hours. Combinations of SAO or LE infusion did not modify the increase in either the plasma CPK activity or the S-T segment following MI. However, SAO shock or infusion of LE increased CPK loss from normal and ischemic myocardium, the loss being greater when MI was combined with infusion of LE or SAO shock. Similarly, MI plus SAO shock increased the loss of the lysosomal protease cathepsin D from normal and ischemic myocardial tissue. Moreover, cats subjected to MI and given LE inhibited increased mortality and decreased clearance of infused lysosomal hydrolases. These results indicate that conditions affecting increased plasma levels of hydrolases promote increased disruption of normal and ischemic myocardial tissue. These findings are consistent with the concept that hydrolases originating in the splanchnic viscera during shock play a role in enhancing damage to normal and ischemic myocardial tissue following coronary artery occlusion.


Energy metabolism of experimental wounds at various oxygen environments. Energy metabolism of healing tissue was studied in experimental wounds of rats chronically breathing 11% O2, air or 55% O2. Increasing oxygen supply elevated both PO2 and PCO2 in the wound tissue. At the early phases of healing hypoxic wounds contained less DNA than normoxic or hyperoxic tissues. In hypoxia the accumulation of wound collagen was clearly retarded. Furthermore, tissue taken from wounds healing in hypoxic environments and tested ex vivo in air showed decreased capacity for glucose utilization, lactate production and oxygen consumption. Concentrations of AMP, ADP and ATP in repair tissue increased as healing progressed. The more oxygen available the higher the amounts of ADP and ATP. The AMP content was not affected by changes in local oxygen tension. These results support the earlier concept that the supply of oxygen in healing tissue may be rate-limitimg. Reduction of available oxygen either by systemic hypoxia or by increased diffusion distance impedes healing.


Influence of vitamin A on wound healing in rats with femoral fracture. Groups of healthy wounded rats with and without comminuted femoral fractures, and maintained on nutritionally complete commercial rat chow with and without supplemental vitamin A, were studied. The test wounds were standard dorsal skin incisions and s.c. polyvinyl alcohol sponge implants. In some experiments the rats were pair-fed; the rats with femoral fracture not receiving supplemental vitamin A were the lead group for determining food allowanced. In other experiments, the rats were allowed food ad libitum. We found that wound healing of rats with femoral fracture was increased when supplemental vitamin A was given, but the supplemental vitamin A did not completely obviate the adverse effects of fracture. The ratio of the breaking strengths of the skin incisions after formalin fixation to the breaking strengths of the incisions in the fresh state was higher in the unsupplemented rats, supporting the results of our earlier experiments that vitamin A increases the rate of collagen cross-linking.


Wound healing in man: tensile strength of healing wounds in some patient groups. The healing of test wounds was studied in 108 patients, in whom some impairment of wound healing was suspected. A 5 cm skin wound was performed in the forearm and the strength of the wound was tested after 5 days using the technique described by Sandblom and associates with two measurements in each wound. No differences in wound strength could be registered between the two wounds in each patient, between males and females nor in patients with malignant disease compared to other patients. Patients with low serum protein or serum albumin values had significantly weaker wounds than patients with normal protein values. Patients over 80 years of age had wounds somewhat weaker than those below 70, the difference having a statistical significance of 6%. The wound strength in patients was compared to values found elsewhere for wounds in rabbits, rats, and piglets. The pigs had much higher values than others, rabbits slightly stronger than and rats about equal to humans.


Infected arterial grafts.

Infected arterial grafts. The case notes of 664 patients who underwent surgery and arterial grafting between the years of 1955 and 1973 at the University of Rochester Medical Center have been analyzed. There were 15 cases of infected grafts-a rate of 2.3%. The outcome of the infection was determined in 12 of these cases. Four patients had no surgical treatment and all 4 died. Three patients had simple ligations with excision and one died, one had an above knee amputation and one continues to have a draining sinus. Five patients had axillofemoral bypasses. Two died and three patients are alive and well. The role of prophylactic antibiotics is briefly discussed and the influence of possible etiological factors is also considered.


Diagnostic peritoneal lavage in evaluating acute abdominal pain. A study was performed to determine the value of peritoneal lavage in the acute abdomen not related to trauma. Lavage was performed in 33 patients in the evaluation of abdominal pain of sufficient degree to warrant consideration for surgical intervention. Peritoneal lavage was truly positive or truly negative in 64% of the cases. It showed false negative results in 28% and false positive results in 8%. The lavage was most accurate in the evaluation of appendicitis, colonic disease, and intra abdominal bleeding. It was highly inaccurate in the evaluation of cholecystitis and peptic ulcer disease. It was concluded that the peritoneal lavage can be a useful adjunct in the evaluation of patients with abdominal pain and should be considered in difficult diagnostic problems but not routinely employed.


Survival improvement following aortic aneurysm resection. Abdominal aortic aneurysm resections were performed on 298 patients between January, 1966 and December, 1973. The results were compared with 186 resections previously reported between 1955-1965. Hospital mortality rates for elective resections were 13% in 1955-1965, 8.4% in 1966-1973, and 4.2% in the 113 patients treated during the last 3 years. Urgent resections for intact aneurysms, previously associated with a 36% mortality, resulted in a 6% mortality rate in 1966-1973. The emergency resection mortality rate for  ruptured aneurysm, originally 69%, was reduced to a present day over-all mortality of 55%, and 42% for the last 3 years. Calculated actuarial survival at 5 years was 65% for urgent (intact), 60% for elective and 40% for emergency (ruptured) groups. Atherosclerosis remains the major deterrent to long-term survival with myocardial infarction and stroke causing 43% of deaths occurring within 5 years. Improved survival appeared secondary to better operative technique, postoperative patient monitoring, increased surgical experience, and more elective resections of smaller, asymptomatic aneurysms than in 1955-1965. With present day low mortality rates, elective resection should be recommended in all patients without significant medical contraindications.


Pathologic pulmonary changes in hemorrhagic shock. Fifty-seven dogs were subjected to hemorrhagic hypotension by a variety of protocols. Histologic pulmonary changes were studied using the light microscope. Of these 57 dogs, 21 had no demonstrable lesions, 8 had minimal changes, and 28 had moderate or severe lesions, all of a focal nature. No correlation was found between the presence of lesions and mean systemic arterial pressure during shock, the udration of the hemorrhagic period, the fate of the animal, preoperative hematocrits and blood volumes, mean postreinfusion arterial pressure, whether the animals were mongrels or purebred beagles, whether they were awake or sedated, whether they breathed spontaneously or were artifically ventilated, whether they had undergone previous splenectomy or not, whether hilar stripping was performed or not, and finally, whether blood was reinfused after hemorrhage or not. Thus we conclude that multiple factors may exert a harmful effect on the lung in hemorrhagic shock, and that shock probably makes the lungs more vulnerable to other injurious agents rather than there being one single pathogenetic mechanism for the pulmonary damage. The term "adult respiratory distress syndrome" rather than "shock lung" is best used for the human clinical entity since it implies a complex ettiology rather than a discrete pulmonary lesion produced by a single pathogenetic mechanism.


Volvulus of the cecum.

Volvulus of the cecum. A series of 37 patients with cecal volvulus treated at three different Swedish hospitals during the years 1952-1973 is presented. The symptoms, physical findings and radiologic features are presented. The associated factors found at operation are described and their possible role in provoking torsion is discussed. In 5 patients the idagnosis did not become clear untio autopsy. Thirty-two patients were subjected to operation. The operation consisted of detorsion in 11 cases, cecopexy in 10, cecostomy in 3 and cecopexy plus cecostomy in 3 patients. The remaining 5 patients were subjected to right sided hemicoloectomy. Of these 5 patients one died postoperatively. There were 6 postoperative deaths after other forms of surgery. The survivors were followed, and the mean followup period was 7 years. There was recurrence in only two patients, both treated with cecopexy. The controversial problem of the preferable surgical method is discussed and a review is given of results in series reported during the last 15 years. It was concluded that when the bowel is viable, cecopexy is the treatment of choice while hemicolectomy should be performed in cases with gangrene.


Cholangitis with acute renal failure: priorities in therapeutics. Obstructive cholangitis with acute renal failure is a dramatic syndrome which merits individual definition. Twenty-one patients with acute suppurative cholangitis complicated by rapidly developing renal insufficiency were studied, and the severity of the renal failure, an acute interstitial tubulopathy, bore no significant relationship to the serum bilirubin level. The mechanism of renal damage was clearly related to episodes of septicemia. Increasing experience has modified the approach to treatment. The dominant septic problem can often be controlled by vigorous antibiotic and fluid therapy, allowing time for spontaneous improvements in renal function. All patients thus operated at a distance from the septic episode survived. If emergency operation is required because of persistent or recrudescnet sepsis, the necessity for dialysis should be considered first; the circumstances demanding dialysis are defined. The priorities in therapy are then: 1) treatment of the infection, 2) treatment of the renal failure, and finally 3) operation. The amount of the operation depends on the evolution of the sepsis, but should be preceded by dialysis when required.


An investigation of endocardial viability ratio in myocardial failure following prolonged hemorrhagic shock. Previous work has documented prolonged survival in dogs subjected to hemorrhagic shock when intra-aortic balloon counter-pulsation (IABC) was instituted in the presence of a 25%-50% reduction in the slope of the left ventricular function curve. Little benefit was noted in the presence of a 75% reduction in slope. In this study, myocardial failure was created in ten dogs by varying periods of hemorrhagic shock. The Endocardial Viability Ratio (EVR) was selected as a method of assessing coronary subendocardial perfusion and was evaluated as a potential method of selecting patients with myocardial failure most likely to benefit from IABC by noting the correlation between EVR and the slope of a simultaneously constructed left ventricular function curve. A significant correlation (r equals .72, p smaller than .001) was noted. The data suggest that a major factor in myocardial failure following hemorrhagic shock is deficient subendocardial coronary perfusion. Variability in data points would make selection of patients on the basis of EVR difficult.


Factors influencing survival following postinfarction ventricular septal defects. Postinfarction ventricular septal defect (VSD) carries a grave prognosis. Surgical closure appears to improve survival. Eighteen patients with postinfarction VSD are reviewed. Nine died before operation could be performed and 9 underwent closure of the VSD; 4 patients are late survivors. Factors which appear to influence survival are: (1) time of surgical intervention after appearance of VSD, (2) presence or absence of cardiogenic shock, (3) location of the infarct, and (4) operative approach to the VSD. Based on these factors, a method of management for postinfarction VSD is outlined.


A comparative analysis of warfarin and low-dose heparin as thromboembolism prophylaxis in total hip replacement patinets. Warfarin, low-dose heparin, or a combination of low-dose heparin and hydrocortisone was administered to 300 patients undergoing total hip replacement. The lowest incidence of thromboembolic (5 per cent) was attained with Warfarin. Further investigation into the method of administration of low-dose heparin is necessary before it can be used effectively as thromboembolism prophylaxis in total hip replacement patients. The addition of hydrocortisone was not found useful.


Advantages of open mind commissurotomy using a triple-orifice technique. Our experience over an eight-year period with the operative relief of mitral stenosis is reviewed and detailed. Of the 106 patients in the series, 80% had minimal or no calcification, 17% had moderate calcification, and 4% had severe calcium deposits in the valve. Four patients have required reoperation for recurrent stenosis, with valve replacement in 3 and a second commissurotomy in the fourth. Left atrial thrombus was encountered in 16%, and no patient with thrombus experienced embolization in the postoperative period. One postoperative death occurred within 30 days, and a single late death occured 35 days after operation. For the scarred, retracted mitral valve we have utilized a multiple-orifice technique that provides maximal flow without the risk of inducing significant mitral insufficiency.


Twelve-year experience with mitral valve replacement. Between 1962 and 1974, 203 mitral prostheses were implanted in 201 patients. Of the 102 survivors, 29 have Beall, 25 Kay-Shiley, 22 Starr-Edwards (SE) 6000, and 27 SE 6320 valves. Full rehabilitation was achieved in 25 patients with Beall and 23 with SE 6320 valves. Sixteen with SE 6000 valves remain normally active. Only 8 with Kay-Shiley prostheses have resumed normal activities. Systemic embolization occurred with the following frequencies per 1,000 patient-months: 13.7 for those receiving the Kay-Shiley valve; 7.2 in the SE 6000 group; 4.3 after SE 6320 implantations; and 3;1 for the Beall group. Other prosthesis-related complications that were much less frequent included detachment (10), bacterial endocarditis (5), and hemolysis (10). Three Kay-Shiley valves malfunctioned. Life table analyses reveal the following survival rates: 33% after 11 years in the SE 6000 patients, 50% after 7.5 years in the Kay-Shiley group, 69% 2.5 years after SE 6320 implantation, and 65% 3.5 years after replacement with a Beall valve. Evidence is presented to support the extension of operative treatment to patients with less advanced valvular heart disease. Postoperative anticoagulation remains an unresolved issue despite lower rates of thromboembolism. More cumulative analyses of survival and morbidity and follow-up hemodynamic data are needed to assess the Beall and SE 6320 prostheses now employed in our valve replacement program.


Prophylactic antibiotics in noncardiac thoracic operations. A high incidence of thoracotomy wound infection and empyema in 1972 was associated with inadequate and irregular administration of prophylactic antibiotics. Beginning with 1973, a strict regimen was adopted that combined systemic cephalosporins and two topical antibiotics (cephalothin and kanamycin). Emphasis was placed on preoperative administration of the systemic agent and on use of the topical drugs before the operative field was contaminated. The patient groups for 1972 and 1973 were similar in most respects, but the wound complication rate was 18.4% in 1972 and 4.8% in 1973.


Removal of myocardial fragment containing a pacemaker electrode. An implanted right ventricular electrode that had become infected and entrapped was removed using continuous traction. Upon removal it was found to be attached to an irregular mass of myocardium 2 to 3 cm long. No unfavorable effects resulted. A new pacemaker was implanted, and the patient has remained well.


[Stable fibrous subaortic stenosis].

[Stable fibrous subaortic stenosis]. The authors studied 37 patients belonging to the Pediatric Cardiology Service of the Institute National of Cardiology who were carriers of fixed fibrinous subaortic stenosis. The diagnosis was established by surgery or autopsy. Isolated subvalvular obstruction was found in 24 patients (63%), which represents the most important number of cases in the literature. The analysis of the 24 cases permitted important conclusions: 1. All the patients had systolic thrills in the suprasternal hollow and carotidinous pathways. 2. No case had protosystolic click. In all, the murmur's epicenter was in the 3rd and 4th IIS in the parasternal line, a fact which can lead to a mistaken diagnosis of interventricular septal defect. 66.6% of the patients had a diastolic murmur heard in the aortic focus, a secondary accompaniement to secondary valvular aortic insufficiency. The intensity of the second aortic sound held an inverse relationship to the magnitude of the gradient. The presence of paradoxic splitting of the second heart sound as well as prolongation of the expulsion period in the carotidogram are indexes for the severity of the obstruction. 3. A relationship between the severity of the lesion and the dilatation of the left atrium was found. The cardiomegaly had no relationship to the severity of the obstruction with the increase in ventricular telediastolic pressure or to the evolution time. 4. An adequate hemodynamic study permits evaluating and locating the site of the obstruction. Likewise, precise ventriculography appraises the nature of the narrowing. 5. Aortic regurgitation is located at the valvular level. Aortography permits its affirmation. Probably the stream coming from subvalvular stenosis produces fibrosis or asynchronism in the closing of the aortic valves. 6. Surgical treatment offers excelent perspectives in mortality as well as reducing the gradient. None of our patients operated on had hospital or later death. 7. Postoperatory evaluation was performed on six patients, and by means of measuring the gradient between the left ventricle and the aorta, the good surgical results could be demonstrated. 8. The natural evolution of patients with fixed fibrous subaortic stenosis is similar to that of other forms of congenital aortic stenosis. Taking into consideration this concept, and before the low risk (0%) in this type of surgery, this is the treatment of choice.


[Clinical electrocardiographic and coronary angiographic findings in 200 cases of ischemic cardiopathies]. A correlative analysis of clinical, electro and angiographic data was carried on, in a series of 200 cases of ischemic heart disease. The possible pathophysiological mechanisms of coronary insufficiency in cases with normal arteriograms, are briefly discussed. Based upon the statiscal results, it can be concluded that there is a close relationship between angiographic findings, and the clinical and electrocardiographic data suggestive of coronary insufficiency.


[Supravalvular aortic stenosis. Report of clinical findings in 5 patients]. Five cases of supravalvular aortic stenosis (SAS) diagnosed by heart catheterization were studied in the Instituto Nacional de Cardiologia of Mexico. The clinic and laboratory data of interest of the differential diagnosis with other forms of obstruction of the left ventricle as follows: 1. Three cases had mental retardation and "elfin" face (SAS with specific psychophysical syndrome), the rest had a normal psyco-physical state without family antecedents (sporadic SAS). 2. The aortic focus was the epicenter of the expulsion murmur. In the phoncarodiographic study, two patients had protosistolic click and another had, in addition, a descending protodiastolic murmur (Int. I-IV). In the radial sphigmograms, one case had an amplitude difference in favor of the right side. 3. All had serum calcium figures within normal limits. 4. A chromosomatic analysis of preperipheral blood was performed on two patients, with normal results. 5. In the electrocardiogram, one case had right ventricular enlargement secondary to pulmonary arterial hypertension, due to stenosis of the main pulmonary arteries. 6. The radiologic study did not show dilatation of the ascending aorta and aortic bud in any case. 7. The angiocardiography showed: stenosis directly above the Valsalva sinuses; absence of dilatation or hypoplasia of the aorta above the stenosis; and the coronary network, indirectly opaqued, showed no abnormalities. One case had aortic coarctation and abnormal implantation of the right sublaviar artery, and another, stenosis of the right and left branch of its origen of the truncus of the pulmonary artery. The literature up to the present is reviewed and an anatomo-functional classification is proposed with the objective of including new varieties.


Corneal arcus and cardiovascular disease in Evans County, Georgia. The population of Evans County, Georgia was surveyed, during a cardiovascular disease study, for the prevalence of corneal arcus. Rates varied with race and sex and increased in prelalence with age in all groups. Arcus was positively correlated with serum cholesterol level. In white males, a significantly higher prevalence rate of coronary heart disease was found in those who had corneal arcues, but arcus was not correlated with subsequent coronary heart disease incidence in any race-sex group.


In-hospital sudden death  after coronary care unit discharge. In a retrospective analysis of in-hospital sudden death among patients with acute myocardial infarction, nine of 48 (18.7%) in-hospital deaths after discharge from the coronary care unit were judged "sudden." This group had a significantly prolonged coronary care unit course, a higher incidence of supraventricular and ventricular arrhythmias, and a noticeable incidence of anterior wall myocardial infarction as compared with those of a matched infarct control group. Seventy-seven percent of the sudden-death group had three or more concomitant high-risk factors as compared with only 3% of a matched control group.


[Myocardial infarct following left ventriculography. Report of 2 cases and review of the literature]. Two cases, a sixteen-month-old girl and a 13 year-old bol, were presented who developed myocardial infarction as a consequence of angiocardiographic study. The boy (case 1) showed electrocardiographic signs of lower necrosis with elevation of the TGO and DHL and having a satisfactory clinic evolution. The girl (case 2), in the electrocardiogram, showed an inactivatable zone on the lateral wall and signs suggesting anteroseptal subendocardic necrosis, and enzymatic elevation. She died the fourth day following the hemodynamic study. The literature regarding this complication and the possible triggering causes are reviewed.


[Hemodynamic consequences of ventriculography in ischemic cardiopathy]. A series of 13 cases of ischemic heart disease, proved by coronary angiography, were submitted to ventriculography in order to study the hemodynamic consequences of the injection of the contrast material. The parameters used to evaluate the ventricular function were the end diastolic pressure, the dp/dt, the VEC and the V. max. A close relationship was observed between the hemodynamic changes secondary to the ventriculography and the degree of coronary involvement. The behaviour of the end diastolic pressure postventriculography can be considered a reliable parameter for evaluating the ventricular functional capacity. Contrariwise, the minimal changes of thee V. max. makes it of doubtful valve.


[Auricular Q wave in right precordial derivations. New sign of left auricular growth]. The authors present four cases of rheumatic heart disease with severe dilatation of the left atrium which reached the right profile in the radiologic study. An initial negative deflexion of the P-wave (qP) in the right precordial leads was recorder in these cases. The presence of qP was interpreted in view of the atrial activation and the solid angle of the right precordial leads as a variation of potential of the right atrial ceiling and/or of the high interatrial septum, a consequence of the dislocation of the right atrium produced by severe dilatation of the left atrium, demonstrated radiologically in the cases studied. Thee presence of qP is another undoubtably valuable sign for inferring a severe displacement of the left atrium toward the right profile.


Bretylium Tosylate; adverse effects in acute myocardial infarction. The effects of bretylium tosylate in managing acute myocardial infarction were studied in 16 patients within 24 hours from the onset of symptoms and were compared to those of lidocaine in a comparable group of 15 patients. Both drugs were equally effective in preventing cardiac arrhythmias during the 48 hours of trial. No deleterious hemodynamic effects were associated with lidocaine treatment. However, marked supine hypotension developed in seven patients treated with bretylium. No changes occurred simultaneously in heart rate, left ventricular ejection time, or central venous pressure. The occurrence of hypotension correlated with a poor initial hemodynamic state. The substantial and unpredictable circulatory effects of bretylium in acute myocardial infarction contraindicates its routine use in the prevention of infarction arrhythmias.


[Mechanism of electric alternance in pericardial effusion. Study with ultrasonics]. Two cases are presented, one with chronic renal failure and the other with a hepatic cyst perforated in the pericardium, with a tension pericardic leakage accompanied with by electrocardiographic alternance. After correct treatment, pericardiocentesis and surgery, respectively, the electrocardiogram lost its electric alternance. The echocardiogram evaluates the importance of the pericardic liquid volume which causes, because of the particular cardiac anatomy, an alternating movement of the heart within the pericardic sac. This factor would be decisive in the origen of the electric phenomenon, a fact corroborated when the electric alternance disappears after pericardiocentesis or surgery.


Rotator cuff tears in rheumatoid arthritis. Rotator cuff tear secondary to chronic synovitis eroding the rotator cuff tendon is a complication of rheumatoid arthritis that has received little attention. Patients with such tears have a long history of active rheumatoid disease preceding the sudden onset of increased unilateral shoulder pain and immobility. The physician may interpret this change as indicating a joint infection or rheumatoid flare, and initiate a drastic change in the patient's therapy. Shoulder arthrography reveals the correct diagnosis. Appropriate treatment consists of heat, rest, range of motion exercises, and repeated intra-articular injection of steroids.


[Mitral valve replacement in children and in adolescents. Surgical indication and long-term results in 86 cases]. 1. The authors present 86 children and adolescents with rheumatic heart disease of the Pediatric Cardiology Service of the Instituto Nacional de Cardiologia who received valve replacements in the period between September, 1964 and April, 1973, a series which is more numerous and of longer follow-up than any published up to the present 2. In order to obtain comparable results, patients with mitral heart disease of other origen and aortic replacement as well as those subjected to double or triple exchange, were omitted from the study. 3. The symptomatology, the presence of compensated heart failure, the progression of cardiomegaly, the radiologic and electrocardiographic changes, the presence of atrial fibrillation, the mean venocapilary, pulmonary arter, and left right ventricle telediastolic pressures, the pulmonary resistence figures and the results of cineangiocardiography were the fundamental elements used to establish the surgical indication. 4. None were operated with clinic or laboratory data suggesting rheumatic activability. The shortest period between the last bout of rheumatic fever and surgery was 10 months. 5. The clinic improvement was remarkable. Half of the cases receiving digitalis and diuretics were released without this prescription and only 10% continue to take digitalis. With the exception of five patients, the physical capacity is normal and most play sports. The postoperatory radiologic and electrocardiographic changes were remarkable, most were obtained a few months after surgery. With the exception of one case, atrial fibrillation disappeared (in 58% before six months in a group of 31 patients). 6. The later complications attributed to the valve replacement as well as the 15 deaths in the total lot were analyzed. It was pointed out that the hospital death rate was 12.6% and the later was 5.3%, extraordinarily low figures if it is taken into account that the material corresponds to nine years of work and the problems inherent to the initial period are included. It gains still greater importance if compared to the series published up to the date. The global mortality rate of 17.9% is small in relation to the only comparable publication, -30 and if only the results of the last three years are compiled (61 cases equals 70 of the series), the global death rate was 9.8%. 7. It was noted that the results are due to the  system adopted for establishing the surgical indication, to the good state of the myocardial fiber...


Coccidioidal synovitis of the knee.

Coccidioidal synovitis of the knee. Four patients are described with documented coccicioidal synovitis of the knee joint. In two of them, no previous diagnosis of coccidioidomycosis had been made prior to diagnosis of coccidioidal synovitis. The other two had active disease after courses of amphotericin B administered both parenterally and intra-articularly for disseminated coccidioidomycosis and coccidioidal synovitis. After synovectomy and limited parenteral amphotericin B therapy, none of the four patients whos evidence of active synovial infection two to seven years later. Synovectomy appears to be an important aspect of the optimal therapy of coccidioidal synovitis of the knee, and when performed, the parenteral dosage of amphotericin B can be limited. Intra-articularly administered amphotericin B is also advocated when possible.


[Conservative management of infected and/or exterior pacemakers. Analysis of 35 cases]. Thirty-five cases of infected pacemakers were revised comparing the results obtained through the conservative attitude in comparison to the traditional attitude. It was pointed out a way to better even further the results obtained through the conservative attitude. Some surgical and medical problems were analized and the way to came through them with respect to this complication, the literature that is in favor of this conduct was also analyzed.


Prevalence of renal disease in asymptomatic heroin addicts. Renal function was studied in 145 asymptomatic male heroin addicts admitted to a methadone detoxification program. The mean duration of addiction was ten years. Three patients had protein excretion greater than 150 mg/24 hr; in one of these, membranous glomerulonephritis was found. All except one had normal creatinine clearance. Hypertension was present in 2.7%. This study does not support the concept that heroin addiction is associated with a high prevalence of renal disease.


[Steinert's disease with cardiac arrhythmia. Morphological findings in the heart conduction system]. This is a case report of a 63-year-old man with myotonic dystrophy in whom an ECG showed atrial flutter, complete A-V block, idioventricular rhythm with image of left bundle branch block and giant, wide and negative "T-U" waves. The microscopic study of the conduction system showed slight fibrosis of the SAN, fatty infiltration and cellular atrophy of the AVN and bundle of HIS, as wells ad basophilic degeneration of a cell at the begining of the left branch and diffuse sclerosis of the left subendocardial ramifications. Advanced coronary atherosclerosis was also found. Since only two complete pathologic descriptions of the heart in myotonic dystrophy have been reported, no definitive specificity could be atributed to this findings. It is suggested that in the present case both coronary atherosclerosis and an intrinsic myocellular dystrophy could have contributed to the final lesions of the conducting system.


Endobronchial metastasis.

Endobronchial metastasis. An attempt was made to define the incidence of tumor metastasis to central bronchi that could clinically mimic primary bronchogenic carcinoma. In a retrospective review of 1,359 consecutive autopsies at Walter Reed General Hospital, metastatic involvement of a major airway was present in only 2% of patients who died with solid tumors. The most common extrathoracic tumors associated with metastatic involvement of a central airway are renal and colorectal carcinomas. The clinical and roentogenographic features of endobronchial metastasis and bronchogenic carcinoma were found to be indistinguishable. However, in the majority of cases the primary tumor site is clinically apparent before symptoms of endobronchial metastasis. In most cases of endobronchial metastasis, the histologic appearance of the bronchoscopic biopsy suggests the correct diagnosis. A central bronchogenic carcinoma should rarely be confused with a metastasis to a major airway from an extrathoracic source.


Porphyria cutanea tarda associated with disinfectant misuse. Porphyria cutanea tarda was detected in a 44-year-old janitress. The illness was probably caused by the unintentional synthesis of a polychlorinated phenol as a result of mixing commonly available household ingredients in toilet bowls and shower stalls. Although the evidence for this hypothesis is circumstantial, its likelihood and the wide-spread household use of these reagents justify calling attention to the innovative misuse of disinfectants as a potential source of toxic exposure.


Spontaneous resolution of pancreatic masses (pseudocysts?)--Development and disappearance after acute alcoholic pancreatitis. To determine the incidence and the natural history of retroperitoneal masses complicating acute pancreatitis, 104 cases of acute alcoholic pancreatitis were evaluated prospectively for mass formation. Abdominal masses detected by physical examination and serial x-ray films of the upper portion of the gastrointestinal tract were localized to the retroperitoneum by additional contrast studies, including abdominal angiography. Nonoperative management was urged only for patients with an asymptomatic mass. An abdominal mass developed in 19 patients (18%). In eight of these, it disappeared rapidly, but in 11 (11%), it persisted, and was considered to be a pancreatic pseudocyst. Eight of the 11 patients were treated nonoperatively, and the mass resolved without complication three weeks to three months after diagnosis. In three patients, a pseudocyst was confirmed at laparotomy. Exploration was justified by an unstable clinical course in only one instance. A routine surgical approach to an asymptomatic retroperitoneal mass developing after acute alcoholic pancreatitis may not be necessaary in patients who are improving clinically because the mass may resolve without complication.


Osteoporosis; evaluation of diagnosis and therapy. Bone mineral content was determined in the radius of 29 osteoporotic patients by the photon absorption method. Mineral content was within the normal range in nine of 24 osteoporotic women. Ratios representing the bone mineral content in the proximal and distal areas of the radius did not distinguish osteoporotic subjects or patients with hyperparathyroidism from normal subjects. Ten osteoporotic women had mineral measurements during a two-year period while receiving placebo or an intake of 2,200 mg of phosphorus and 2,400 mg of calcium. No increase in radial mineral content was observed during this regimen or after adding vitamin D. We conclude that the mearurement of mineral in the radius does not always accurately reflect the overall skeletal mass in an individual patient and that prolonged therapy with high phosphorus and calcium intake did not increase the radius mineral content.


Hearing and diabetic neuropathy.

Hearing and diabetic neuropathy. Hearing was studied audiometrically in 20 diabetic patients with peripheral neuropathy, and the results were compared with those from a group of normal, age-matched subjects. Although the patients gave no history of hearing loss or ear disease, 11 (55%) had symmetrical sensorineural hearing loss involving at least one frequency. Regression analysis demonstrated significantly higher hearing thresholds for the diabetic group at nine of 11 frequencies tested. Decreased hearing acuity in diabetes mellitus may be related to neuropathy of the auditory nerve.


Jaccoud arthritis.

Jaccoud arthritis. Jaccoud polyarthritis is thought to be a rare complication of rheumatic fever. It is characterized by severe rheumatic fever, with repetitive or prolonged attacks, associated with a painless, but deforming arthritis affecting the small joints of hand and feet. Radiologically, erosion of the metacarpal heads may be present. All described cases have shown obvious rheumatic heart disease. Two patients had the clinical and radiographic features of Jaccoud arthropathy who had no antecedent history of rheumatic fever. Jaccoud arthropathy may have diverse causes.


Reversible nephrotoxicity associated with cephalothin therapy. A 53-year-old man with scalp cellulitis developed acute renal failure after sodium cephalothin therapy. The patient probably had preexisting renal disease. Discontinuance of cephalothin was followed by improvement of the renal function. Specimens from a renal biopsy performed during the recovery phase showed nonspecific changes in the renal tubular epithelium, similar to those seen in animals treated with large doses of cephalothin. Previously reported cases of cephalothin nephrotoxicity, along with this case, caution the clinician to proceed with care in the treatment of azotemic patients with cephalothin.


Calcific cardiomyopathy in advanced renal failure. Four uremic patients on maintenance hemodialysis developed intractable heart failure and atrioventricular block. All had persistently high (over 60) calcium-phosphorus products. At autopsy, all had metastatic myocardial calcification. Their inability to take phosphate-binding agents orally is responsible for this fatal complication.


The Jewish Hospital of St. Louis therapeutic grand rounds number 10. Chemoprophylaxis of tuberculosis. Isoniazid therapy has been proved an effective means of preventing overt clinical tuberculosis in persons with positive tuberculin skin tests, persons who are close contacts of active cases, and persons with inactive tuberculosis that were never treated. The administration of isoniazid in standard dosage for one year in these situations will help greatly to reduce tuberculosis as a community health problem in the future. Studies in recent years, however, point to hepatic dysfunction as a complication of isoniazid therapy in up to 10% of patients. In a few patients, liver disease as a complication of this therapy has been fatal. The likelihood of this complication increases with age. Accordingly, isoniazid chemoprophylaxis should be undertaken with the understanding that the patient has to be followed up closely, especially for evidence of liver disease during the course of therapy. This potentially serious side effect suggests that isoniazid chemoprophylaxis should be used primarily with patients in high risk groups.


A multilingual self-administered symptom history. A multilingual computer-derived symptom history was developed from a two-stage yes-no symptom questionaire, based on a library of 4,000 numbered questions. The English primary and secondary questionaires were translated into German, Italian, French, Spanish, Greek and Yugoslav. "Yes" answers to the numbered primary questions presented in these languages were processed by a computer that generated individualized secondary questions in the same language. "Yes" answers to these numbered questions were processed by a second computer program that printed out the narrative history in English. As well as other benefits of automated symptom histories, there is now a facility for the computer to acquire a patient's history in one language and print it out in any other.


Olivopontocerebellar degeneration. Clinicopathologic correlation of the associated retinopathy. In two siblings with olivopontocerebellar degeneration, the retinal pigment epithelium or the sensory retinal or both appeared to be damaged first. These layers were markedly involved before secondary changes in the choriocapillaris, the inner retinal layers, or the optic nerve occurred.


Norepinephrine in treatment of ocular hypertension and glaucoma. Norepinephrine (4%) as free base produced a significant fall in intraocular pressure and resistance to outflow. This effect was sustained for up to 20 weeks. No significant difference could be shown between the effect of 2%, 3%, and 4% norepinephrine on the aquious humor dynamics. The effect on pressure and facility was shown in eyes with ocular hypertension and with glaucoma. An additive effect was observed after use of norepinephrine with pilocarpine in the treatment of glaucoma. Crossover studies between epinephrine borate 1% and norepinephrine borate 4% revealed no significant difference. Like epinephrine, norepinephrine produces a conjunctival hyperemia in many patients. However, there is an absence of tachycardia after use of norepinephrine, and one person in this study showed an allergic reaction to epinephrine that cleared promptly and completely when norepinephrine was substituted.


Ceroid-lipofuscinosis (Batten disease). Fluorescein angiography, electrophysiology, histopathology, ultrastructure, and a review of amaurotic familial idiocy. Three children with ceroid-lipofuscinosis and their mother wer investigated fluorescein angiographically and electrophysiologically after definitive diagnosis of the oldest child had been made from a brain biopsy specimen studied biochemically, histopathologically, and ultrastructurally. The diagnostic features of the two classes of familial amaurotic idiocy (the gangliosidoses and the ceroidlipofuscinoses) are reviewed with emphasis on the importance of the fundus picture and fluorescein angiographic study in differentiating the two classes of disease and in identifying affected siblings.


Optochiasmatic arachnoiditis in multiple sclerosis. A patient had visual field loss and optochiasmatic arachnoiditis and subsequently developed other evidence of multiple sclerosis. The possibility is raised that many of the "idiopathic" cases of optochiasmatic arachnoiditis may have a similar origin. Special emphasis is placed on the functional role of the fibrosis in the pathogenesis of optochiasmatic arachnoiditis.


Experimental vortex-choroidal angiograms. The choroidal circulation completely separated from the retinal circulation has not, to our knowledge, been previously demonstrated by fluorescein angiography. This has been accomplished in owl monkeys and rabbits by direct injection of fluorescein via a catheter introduced into a vortex vein by microsurgical technique. Morphologically distinct choroidal venous and arterial patterns were angiographically demonstrated in monkeys and rabbits. Some direct perfusion to the optic disc from the adjacent choroidal circulation was demonstrated in both species.


Photodynamic inactivation in experimental herpetic keratitis. The effect of photodynamic inactivation on experimental herpes simplex keratitis in rabbits was investigated using neutral red as a photosensitizing dye followed by exposure to light at 425nm. Combined dye application and light exposure early in the disease (two days following infection) reduced to a minimal extent the severity and duration of the acute epithelial infection. The effect on well-established keratitis (three days postinfection) was negligible as evaluated by clinical grading, viral recovery, and histopathological study. In initial experiments, it was found that the dye and light did not have any observable deleterious effect on intact corneas or cause any noticeable delay in healing of injured cornias. Further, when light or dye were utilized alone, neither changed the severity or duration of the keratitis. In vitro treatment of the virus with light and dye destroys its ability to produce experimental keratitis.


Corneal endothelium in viral induced anterior uveitis. Ultrastructural changes following canine adenovirus type 1 infection. Dogs inoculated intravenously with attenuated canine adenovirus type 1 developed anterior segment inflammation and corneal edema. During the stage of mild anterior uveitis, virus was isolated from the aquious fluid, and by electron microscopy, viral replication was found to occur in corneal endothelial cells. Later, at the stage of severe anterior uveitis with corneal edema, virus was not isolated from the aqueous fluid and cells containing intranuclear (replicating) virus were not found. At this stage, many inflammatory cells had infiltrated the anterior chamber and contained numerous membrane-bound viral aggregates (viral-antibody complexes). Phagocytized viral-antibody complexes were present in the areas of most prominent endothelial cell destruction. Peripheral to the principal lesion sites, inflammatory cells had dissected the endothelium from Descemet membrane. After recovery from the disease, an intact endothelial cell layer was present.


Idiopathic malignant hyperthermia. Review and report of a case. All physicians performing surgery while the patient is under general anesthesia must be aware of the existence of idiopathic malignant hyperthermia. A young adult had a malignant hyperthermic reaction despite four prior uneventful administrations of general anesthetics. To my knowledge, this is the first report of a patient who survived following a hyperthermic reaction, having sustained considerable residual brain damage. There is a great need for continuous body-temperature monitoring during general anesthesia.


Acute posterior multifocal placoid pigment epitheliopathy. A recurrence. Acute posterior multifocal placoid pigment epitheliopathy recurred in a 23-year-old white woman. Forty-two days after the onset of symptoms and following the complete resolution of the initial bilateral lesions, a second crop of ophthalmoscopically and biomicroscopically similar lesions were seen in each eye. The cause of the disorder is unknown, and corticosteroid therapy is of doubtful benefit.


Corneal perforation and iris prolapse due to Mima polymorpha. An 11-year-old girl had hyperacute conjunctivitis but was lost to follow-up until nine days later when she returned with a corneal perforation and iris prolapse. A smear at that time showed Gram-negative intracellular diplococci, but subsequent bacteriological study revealed the causative organism to be Mima polymorpha. This apparently is the first documented case of corneal perforation due to Mimeae, and emphasizes that Mimeae can be completely indistinguishable, clinically and on smear, from infection caused by Neisseria. Only a high index of suspicion and the proper bacterial cultures can prevent a possible tragic misdiagnosis.


Prism placement. Measurements of horizontal and vertical deviations with the head tilted. While performing prism and cover measurements for strabismus with the head tilted, prisms held before the eye should be positioned so that the base of the "horizontal" prism is parallel to the lateral wall of the orbit, and the base of the "vertical" prism is parallel to the floor of the orbit. This placement is required because with the head tilted, torsional compensation of the globe is minimal.


Iris angiography in cystoid macular edema after cataract extraction. Iris angiography was performed on eight patients (nine eyes), who had cystoid macular edema postcataract extraction. The fundus fluorescein angiographies showed typical star-shaped, multiloculated staining of the macular area. The iris angiographies demonstrated moderate to massive leakage of dye from the iris, and possibly leakage of ciliary body vessels into the anterior chamber, thus evidencing the until now suspected but undocumented fact that fluorescein leakage is not restricted to the fundus vessels. These data tend to support the idea that this type of macular edema is due to a vascular abnormality, and not to altered vitreous mechanics.


Quinoline analog labeled with iodine 123 in melanoma detection. Using the Greene melanoma in the hamster (Syrian Golden), the radiopharmaceutical, 123-1-4(3-dimethylaminopropylamino)-7-Iodoquinoline, was tested for its ability to localize melanoma. This quinoline analog has been described for use in the detection of melanoma, but this is the first report, to our knowledge, of its being used with an 123-l label. Hamsters with either skin or eye melanomas were studied. Both melanomas could be seen with a gamma camera at three hours after injection. In vitro analysis confirmed the tumor specificity. Thus, it appears that this preclinical trial of a new radiopharmaceutical justifies clinical testing to determine its value in the localization of melanomas of the eyes and skin of humans.


Internuclear ophthalmoplegia of abduction. Isolated impairment of phasic ocular motor activity in supranuclear lesions. Abduction saccadic movement slowed to either side without any limitation in the end position occurred in a patient. This ocular motor abnormality constituted a mirror image of the well-known internuclear ophthalmoplegia of abduction. Intermuclear ophthalmoplegia of either type demonstrates that a lesion between the center for conjugate gaze and the ocular motor nuclei can impair phasic activity of the eye muscles without reducing their tonic function.


Pseudoparalysis caused by anomalous insertion of superior rectus muscle. Congential ectopia of the insertion of the superior rectus muscle to the superior border of the lateral rectus muscle was seen in a 4-year-old child. In all respects, this condition mimicked congenital superior rectus palsy. The resultant large hypotropla was completely corrected by repositioning the superior rectus to its normal anatomic position.


[Characteristics and aims of modern centers of audio-phonetics]. The organisation and aims of a modern audiology and phoniatrics centre are described. In children the centre identifies hearing defects as early as possible, and provides for re-education, to facilitate acceptance in normal society. In adults the centre arranges schemes for the prevention or limitation of occupational deafness, and makes a precise assessment of the degree of severity and type of lesione encountered as a result of any other aetiopathogenic factors, suggesting the most appropriate forms of therapy (medical, surgical or prosthesis). Conventional audiometry methods are employed, together with the most recent types of objective audiometry (psychogalvanometry, electroencephaloaudiometry, electrocochleography).


[Surgical leg lengthening].

[Surgical leg lengthening]. The operative lengthening of tibia and fibula. After a brief bibliographical survey of the principal method adopted in the operative lengthening of tibia and fibula, the Authors consider the risk and complications involved in this operation. They then examine the case histories of patients operated during the period 1969 1973 and discuss the data, the limitations of the operation and the results obtained.


[Anatomo-topographical and structural aspects of the dorsal nucleus (Clarke's nucleus) in humans]. There is fairly plentiful old and recemt literature on the dorsal nucleus (Clarke's nucleus), but the research reported is mainly in animals. The present study covers human material (9 spinal cords), considered mostly from the morphological-topographical aspects. In man, Clarke's column is not perfectly symmetrical, is "clublike" in shape, and reaches from the eighth cervical to the second lumbar segment. The left is slightly larger than the right. The large Clarke's cells typical of this nucleus are fewer in the cranial than in the caudal segments, with 14 percent more Clarke's neurons in the left-hand column. The staining methods used (Bielschowski, Weiger, Nissl) permitted topographical, overall and comparative study of the Clarke's neurons, revealing a thick layre of interneuronal and intra-columnar amyelin fibres dividing the nucleus thoracicus into two distinct zones. In conclusions, some morphological and functional hypotheses are put forward, based on the Author's observations.


[Isolated fracture of the transverse apophysis of the 1st dorsal vertebra]. The Authors describe a case of isolated fracture of first dorsal left transvers apophysis observed in Orthopaedic Clinic of Parma University. It's an exceptional lesion: infact till now only six cases of this type of lesion are been presented in orthopaedic literature.


[Various genetic and clinical aspects of patients with hemolytic anemia caused by glucosephosphate dehydrogenase deficiency (DG6F)]. Five families with DG6F deficiency were studied. Out of the first family, neinatal hyperbilirubinemia was evident in 3 children. Exchange transfusion was given to the first two. Possibly, the hemolytic crisis was subsequent to the application of vitamin K. In the next family group, there is a history of 6  children dead from jaundice and deep dark urine. Partial deficiency was found in the wife and 3 children from the third family. Fortunately, the father who is the brother of a deficient patient, shows normal levels. In family number four, both the father and the mother show below normal levels of DG6F. They have a sick son and daughter with subnormal levels. In the last family, the mother carried and the father shows abnormal levels of the enzyme; consequently, a son and their 2 daughters complain from the diseases. It is pointed out that some drugs, infections and several foods may precipitate the hemolytic crisis and brief comments are made on diagnostic and therapeutic resources.


[Persistence of lymphocytotoxic antibodies in multiparas examined several years after their last pregnancy]. Cytotoxic antibodies were searched in 422 pregnant women at different times after the last pregnancy (1 to 42 years). The percentage of antileukocytes isoimmunization was 12%. There was no correlation between cytotoxic antibodies and frequency of abortion. The role of cytotoxic isoantibodies during pregnancy is discussed.


[Malignant reticuloendothelioses. Clinical variations influencing prognosis]. The relationship of age, sex, clinical findings and prognosis was studied among 30 children with malignant reticuloendotheliosis. A male predominance was found, but it was not possible to make any prognostic correlation regarding this parameter. A definitive worse prognosis was found in the early ages, thus 88% of less than 12 months-old children died. Although the visceral involvement degree signifies a poor prognosis, it was found that nevertheless, a solitary osteolytic lesion is in the accordance with good prognosis; all patients who did not have bone lesions died in less than three years. It is the first part of our purpose to enact the usefulness of the clinical findings toward a more precise prognosis in the malignant reticuloengotheliosis. Later on, we will report the possibility to obtain a numerical data from the clinical findings in order to establish an accurate prognosis.


[Esophagogastric resection in patients with esophagogastric varices]. The authors carried out a revision of the patients in whom esophagogastric resection resection had been practiced as treatment for varices in the extrahepatic portal hypertensive syndrome. They added up to 13 cases out of which, 11 were with exophagogastroanastomosis and 2 with transposition of colon. Out of the 11 patients in whom esophagogastric resection and anastomosis and 2 with transposition of colon. Out of the 11 patients in whom esophagogastric resection and anastomosis of stomach to esophagus was practiced, 8 are well (72%) and 3 died. Out of 2 cases where a segment of colon was interposed, one followed a satisfactory course (50%), but the other one died. All deaths occurred during the immediate postoperative stage. The technique followed, together with its indications, is described and the conclusion is that, although this method is only palliative, it allows to extend the life of the patient and permits the chance to wait for a later stage when a definite operation may be performed.


[Determination of prothrombin (factory II) in one step using Taipan venom]. A new one-stage prothrombin assay using Taipan venom is presented here. Taipan venom converts prothrombin to thrombin in the absence of all coagulation factors known up to the date. The prothrombin concentration in normal adults varied from 64.0% to 159.0% with a mean of 100.64% plus or minus 24.83%.


[Chronic interstitial nephritis caused by analgesics]. Interstitial nephritis secondary to analgesic ingestion is apparently an uncommon subject in pediatric literature. Two cases are reported in this article: case 1 is a girl followed for the last fifteen years when she had lipoid nephrosis which was treated initially with corticosteroids; she responded satisfactorily, but presented frequent relapses. After 8 years, she was given cyclophosphamide plus prednisone and lately, she responded and has remained well. Further on, her urinalysis showed specific gravity of 1,033 and no proteinuria. Five years ago, because of protracted headache due to psychological disturbance, she started to ingest a variety of analgesics in progressively increasing doses. For the last 2 years, abdominal pains, paleness, polydipsia and polyuria have been observed; at present, her blood pressure, serum chemistry, and urine sediment are normal, but there is a marked failure in the renal concentration capacity, as well as marked sodium urinary losses. A percutaneous renal biopsy showed tubulo-interstitial fibrosis and edema with normal glomeruli. Case 2 is a girl with rheumatoid arthritis which appeared 3 years ago; for over one year, the patient was given 15 mg/day prednisone plus 1.5 g. acetylsalycilic acid. She was admitted to the hospital because her osteoarticular problem did not improve. Her blood pressure, blood chemistries and urinary sediment were also normal. LE tests were negative. Renal concentrating capacity was reduced and the renal biopsy showed tubular atrophy; there was intestinal edema and mononuclear infiltration. Chronic interstitial nephritis, secondary to analgesics is supported in both cases; polyuria and a marked defect of renal concentrating capacity are the earliest and most characteristic features. Normal urinary sediment is a common finding leading to erroneous assessment of a lack of renal involvement. Pathological lesions are located in the interstice of the renal medulla and sometimes in the papilla. Early arrest of analgesic ingestion may stop and even reverse the renal lesion and the renal insufficiency.


[Comparison between the 3- and the 24-hour urine collection for creatinine clearance]. Endogenous creatinine clearance was studied in thirty children with various renal diseases and variable degrees of functional deterioration. Two different procedures or urine collection were used on each child: 1) twenty-four-hour urine collection with one blood sample and immediately afterwards 2) three one-hour consecutive periods of urine collection, with one previous blood sample (the one used for the 24-hour procedure). Both procedures were carried out during hydration of the patient and creatinine was determined with the autoanalyzer in urine and blood samples. The results obtained with both procedures did not show significant difference. The three-hour periods procedure may be recommended for hospitalized patients, specially infants or young children, and also when the parents are not reliable enough for hydrating the patients and for performing a complete collection of urine in a 24 hour period.


[Diagnostic value of jejunal biopsy].

[Diagnostic value of jejunal biopsy]. Trying to find out the clinical elements that define the precise indication ofr a jejunal biopsy, 28 children with several pathological conditions were studied. They were 12 cases of kwashiorkor, 11 cases with chronic diarrhea, two cases of chronic pancreatitis, 2 cases with ferropenic anemia resistant to the oral treatment with iron and one case of chilous ascitis. It is concluded that only in those cases in which the biopsy is the precise medium for diagnosis is where it would be indicated, such as intestinal lymphangiectasis or in those cases with signs or evidence of malabsorption without diarrhea. The chronic diarrhea per se does not seem to be a formal indication for biopsy.


[Effect of environmental humidity on the epistaxis of patients with acute thrombocytopenia]. The effect of humidification of the environment was studied on the frequency and severeness of spistaxes in a group of 16 children. A control group was composed of 18 children with the idea that they were similar, but the hematologic conditions of the latter group were more unfavorable. A decrease of epistaxis was not found; there was a minimal prolongation of the days between one and the next nosebleeding picture. A definite decrease in the severeness of bleeding was found in the second group as judged by a lesser necessity of transfusions.


[Libernan-Cole-Golts syndrome. Focal dermic hypoplasia. Report of a case]. A case is reported corresponding to the so-called focal dermic hypoplasia and that we have named Liberman-Cole-Goltz syndrome. This is possibly the fourth case published in Mexican literature and is an additional report to those described in the international literature. This syndrome is characterized by variable ectodermal and mesodermal defects with congenital lesions most frequently found in skin and in the skeleton. The clinical, radiological and histopathological finds in the case studied are pointed out.


Measurements of conduction times with catheter electrodes during pacing from different ventricular sites. Filtered bipolar catheter electodes, I mm apart, were used to pace and record from the high right atrium, right ventricular apex, right ventricular outflow tract, right ventricular inflow tract, middle cardiac vein, great cardiac vein, and endocardium of the left ventricular septal surface. Right ventricular apex to middle cardiac vein and the middle cardiac vein to right ventricular apex conduction intervals gave a rough estimate of anteroposterior and posteroanterior "transseptal plus free left ventricular wall" conduction times, respectively. On the other hand, the right ventricular apex to left ventricular septal surface and left ventricular septal surface to right ventricular apex intervals represented pure "transseptal" conduction times, since both sets of electrodes were in contact with the respective septal surface. During stimulation of the intermediately located right ventricular inflow tract propagation to the right ventricular apex and right ventricular outflow tract was longer than between these two sites. Moreover, conduction was almost as delayed to the right ventricular apex and right ventricular outflow tract as it was to the left ventricular septal surface. These findings were attributed to the peculiar electrophysiological behaviour of the right ventricular inflow tract muscle. Pacing from different segments of the great cardiac vein produced QRS morphologies and arrival of excitation patterns consistent with the relation between the anatomical location of this structure and the recording electrodes. However, from this study no inferences could be drawn regarding the conduction velocity or specific conduction pathways used by the stimulus in its journey from stimulating to recording areas.


Normal pattern and physiological significance of mitral valve flow velocity recorded using transseptal directional Doppler ultrasound catheterization. In 10 cardiac patients in whom an organic lesion of the mitral valve was exluded by standard investigation procedures during which a diagnostic transseptal catheterization for pressure measurements in the left heart was performed, the authors placed a directional Doppler ultrasonic catheter tip velocimeter at the site of the mitral ring and recorded the mitral flow velocity traces. The pattern of these normal curves is presented and a physiological interpretation proposed. The relation between the mitral flow velocity and low volume curves is discussed in the light of present experimental data on mitral valve flow velocity profiles and variations in size of the mitral orifice. The authors concluded that the flow velocity curves obtained by the Doppler technique constitute a valid physiological reference system for the study of the mitral valve flow velocity tracings that can be recorded in the various forms of mitral valve disease.


Diagnosis and evaluation of mitral valve disease using transseptal Doppler ultrasound catheterization. In 33 patients with confirmed mitral valve disease, the mitral valve flow velocity traces were recorded by means of a directional Doppler ultrasonic velocimeter using the transseptal route, and correlated with the clinical and haemodynamic data. In all cases, characteristic anomalies of the mitral flow velocity patterns were noted and could be related to the type of lesion, stenosis, regurgitation, or a combination of these. Furthermore, specific patterns of the flow velocity traces were shown to correlate satisfactorily with the degree of severity of the disease. The authors propose a pathophysiological interpretation of the anomalies of the velocity patterns, based on turbulence for stenosis and backward flow wave for regurgitation. They conclude that the transseptal directional Doppler catheterization provides a new reliable method for establishing the diagnosis and grading the severity of mitral valve disease using pattern recognition, and, moreover, offers a new approach to the understanding of mitral haemodynamic disturbances on a beat-to-beat basis.


Effects of high altitude hypoxia on left ventricular systolic time intervals in man. Effects of high altitude hypoxia on systolic time intervals were examined in 34 healthy men: 20 sea level residents studied at rest and at the end of 3 minutes steady isometric (handgrip) exercise at sea level and then serially for the first 5 days and on the tenth day, at an altitude of 3658 m, and I4 permanent residents at high altitude studied at high altitude. In the sea level residents there was a significant increase in the pre-ejection period (PEP), abbreviation of the left ventricular ejection time (LVET), both corrected for heart rate, and prolongation of the PEP/LVET ratio at high altitude. The maximum changes were seen on days 2 and 3; these parameters tended to approach sea level control values by the tenth day. The systolic time interval values of high altitude residents were similar to the control values of the sea level residents obtained at sea level but significantly different from the changes in the sea level values seen in the first 4 days at high altitude. It thus appears that while the high altitude residents do not show any left ventricular dysfunction as determined by systolic time intervals, healthy sea level residents when exposed to high altitude hypoxia show a significant depression of the left ventricular function for at least the first 4 days. This might be a contributing factor in the genesis of high altitude pulmonary oedema.


Continuous electrocardiographic recording during exercise in young male diabetics. A computer study. Forty selected young patients with diabetes of medium to long duration and 26 control subjects without clinical evidence of ischaemic heart disease were studied using a new and sensitive technique of electrocardiographic recording during exercise with continuous computation of the time course of the ST-T segment changes to detect possible early ST depression indicative of ischaemia. Although no such evidence was found, significant differences in the diabetics were observed in the heart rate and ST-T segment, the latter changes having not been previously reported but which may be attributed to ischaemia or alternatively to autonomic neuropathy in the "presymptomatic" phase.


Isolated ventricular inversion with situs solitus. The clinical and anatomical findings in two patients with isolated ventricular inversion and situs solitus are described. The other 4 previously published cases are reviewed. The 6 patients with this malformation, all without pulmonary stenosis, presented a clinical picture of cyanotic congenital heart disease, associated with increased pulmonary blood flow (hypoxaemia and cardiac failure). The importance of different diagnostic tests is discussed and it is concluded that angiocardiography is the only definitive means of establishing the dianosis. Because the physiopathological disturbance is the same as in transposition of the great arteries, both malformations should be similarly considered with respect to diagnosis and treatment. Nevertheless, the high incidence of certain associated malformations in cases of isolated ventricular inversion adds to difficulty in diagnosis, and makes a good result from the Mustard procedure less likely than in transposition of the great arteries.


Plasma and tissue digoxin concentrations in patients undergoing cardiopulmonary bypass. Plasma myocardial, and skeletal muscle digoxin concentrations were measured in 32 patients undergoing cardiopulmonary bypass who were on long-term treatment with digoxin. The patients were divided into 4 groups according to the daily digoxin dose and the interval between discontinuation of the drug and operation. Before bypass, the mean digoxin concentrations were 1.58 nmol/l (1.24 ng/ml) in plasma 65.2 nmol/kg (50.9 ng/g) in the atria, 121.4 nmol/kg (94.98 ng/g) in 11 papillary muscles, and 16.6 nmol/kg (13.0 ng/g) in skeletal muscle. Mean atrial digoxin concentrations were significantly lower tham mean papillary muscle concentrations in 11 patients. Ratios of plasma of myocardial or skeletal muscle digoxin concentrations were very variable. Generally digoxin concentrations were higher in patients on the larger digoxin dose and with the shorter discontinuation time before surgery. These differences attained significance only with plasma digoxin concentrations. There was a slight fall in plasma digoxin concentration during cardiopulmonary bypass but no significant differences were observed between plasma, atrial, or skeletal muscle digoxin concentrations before and at the end of bypass. No clear relation was seen between plasma or atrial digoxin concentrations and postoperative cardiotoxicity. Stopping digoxin 48 hours before operation appeared to account for pre- or post-bypass plasma digoxin concentrations of less than 1.0 nmol/l (0.8 ng/ml) in most of the instances encountered, whereas the 3 patients who developed pulsus bigeminus postoperatively had received 0.5 mg digoxin only 24 hours before operation.


Sinoatrial block. Autonomic influences and clinical assessment. Seventeen patient with sinoatrial block and 16 healthy volunteers were investigated with recently developed autonomic tests of atrial pacemaker function. Only one patients was found to be entirely normal in comparison with normal subjects, while another patients had supernormal responses. Fifteen patients had reduced responses relative to the controls implying impaired atrial pacemaker function or sinoatrial disease. It is suggested that while in some cases sinoatrial block may be of physiological origin, it is more often due to sinoatrial disease. The latter group are liable to Adams-Stokes syncope and may have additional atricventricular conduction abnormalities. The possible mechanisms and treatment of sinoatrial block are discussed relative to the autonomic and pacemaker function abnormalities described.


Infective endocarditis in the billowing mitral leaflet syndrome. Ten patients with the billowing mitral leaflet syndrome complicated by infective endocarditis are reported. Two patients had a non-ejection systolic click and 8 had both a non-ejection systolic click and a late systolic murmur. These auscultatory features were difficult to detect in 4 instances in that they were intermittent, soft, or brought out only with postural change. Seven patients were unaware of their cardiac lesions. A low grade pyrexia was present in all 10 patients. Four patients presented with clinical features caused by reversible neurological lesions. Blood cultures were positive in all patients, with Staphylococcus albus the infecting organism in 6. Antibiotic therapy was successful with significant mitral regurgitation supervening in only one instance. The importance of the billowing leaflet as a potential site of infective endocarditis is emphasized. It seems that antibiotic prophylaxis is indicated at times of increased risk of infection in subjects with a non-ejection systolic click or a late systolic murmur.


Studies in a newborn infant with supraventricular tachycardia and Wolff-Parkinson-White syndrome. A neonatal patient with Wolff-Parkinson-White type A and supraventricular tachycardia is described. Demonstration of the mechanism of the tachycardia and its termination were achieved using intracardiac electrography and cardiac pacing. Quantitative left ventricular angiography and echocardiography showed impaired left ventricular function following the arrhythmia. Serial echocardiograms demonstrated the subsequent return to normal left ventricular performance.


Malignant hypertension associated with use of oral contraceptives. A 26-year-old woman who had been taking an oral contraceptive preparation for two years developed malignant hypertension. Investigation failed to elicit any renal or other cause for her hypertension, but control of blood pressure was obtained by withdrawal of the oral contraceptive agent and antihypertensive therapy. Subsequently, after withdrawal of therapy, the blood pressure remained near normal. The patient had a previous history of hypertension during pregnancy; she was also overweight.


Bidirectional tachycardia in a child. A study using His bundle electrography. This is a report of a case of bidirectional tachycardia in a 6-year-old girl with no evidence of any structural abnormality of the heart. The patient had never received digitalis. The arrhythmia appeared to be precipitated by effort and emotional stress, and could be induced by increasing the heart rate by atrial pacing or isoprenaline administration. His bundle electrography showed that the arrhythmia was ventricular in origin. This emphasizes the importance of recording an effort electrocardiogram in all children with unexplained syncopal episodes, even when the resting electrocardiogram is normal.


The effects of magnesium deficiency of ketamine sleeping times in the rat. Young growing rats were maintained on a magnesium deficient diet, and injected with ketamine after 7, 11, 14, and 18 days on the diet. A comparison of the sleeping times, as measured by the loss of the righting reflex after injections of three doses of ketamine, was made with rats similarly maintained on a control diet. Tolerance with successive injections to ketamine, indicated by a decrease in sleeping time, was noted only among the control rats. After 14 and 18 days on the diet, the magnesium deficient rats showed no tolerance to the earlier injections, but their sleeping times were longer than their control counterparts. In rats injected for the first time on day 14 of the diet, the magnesium deficient rats showed significantly longer sleeping times than the control rats; this suggests that the difference in sleeping times between groups is not entirely dependent upon the development of tolerance to the drug seen in the control rats. In addition, a sex difference was noted, with female rats sleeping longer with ketamine than male rats.


Determination of the minimum alveolar concentration (MAC) of halothane in the white New Zealand rabbit. The minimum alveolar concentration (MAC) was determined in rabbits as the mean of the lowest alveolar halothane concentration preventing and the highest permitting a response to stimulus. MAC for the rabbit was 0.8 plus or minus 0.3 per cent. The measurement of MAC in the rabbit appears to reflect the arterial and brain anaesthetic concentrations.


Clinical studies of induction agents. XLIII: recovery from althesin--a comparative study with thiopentone and methohexitone. A detailed assessment of recovery endpoints and a simple performance test were employed to investigate recovery from anaesthesia. 150 patients participated in a comparative study using different doses of Althesin, thiopentone and methohexitone. Althesin was found to be suitable anaesthetic agent for the outpatient practice, although recovery was not as rapid as that following methohexitone.


The use of propanidid for blind nasotracheal intubation. Blind nasotracheal intubation has been attempted in 72 patients under light general anaesthesia with propanidid in a one-dose or two-dose technique which provides conditions for up to six attempts. Nasotracheal intubation was achieved in 49 patients with a one-dose technique, and in a further 15 patients with the supplementary dose. It is suggested that this technique with propanidid is  safer than other techniques using non-anasthetic respiratory stimulants with their attendant dangers, and that the success rate with propanidid is similar to that using these other techniques.


A technique of ventilation during laryngoscopy and bronchoscopy. A technique for  ventilating patients thorugh a catheter with nitrous oxide and oxygen utilizing the venturi principle is described for patients undergoing laryngoscopy or bronchoscopy. Arterial blood-gas measurements in 34 patients reveal that ventilation was adequate.


Automatic flow interruption bronchoscope: a laboratory study. A laboratory assessment of a ventilating bronchoscope incorporating automatic flow interruption suggests that it will safely adequate ventilation.


Immediate changes in plasma potassium, sodium and chloride concentrations induced by suxamethonium. Four groups of healthy female patients were anaesthetized with wither thiopentone, Althesin or nitrous oxide-oxygen with and without halothane. The concentrations of the plasma electrolytes were measured before and at varying times up to 10 min after the administration of suxamethonium 1 mg/kg. Asmall, but significant, biphasic increase in plasma potassium concentration was found when suxamethonium was administered to patients in whom anaesthesia was induced with thiopentone, Althesin and nitrous oxide-oxygen. The initial increase in plasma potassium concentration was greater in the Althesin group thanin the other two groups. A more delayed, but sustained, increase in plasma potassium concentration was found following induction with nitrous oxide-oxygen-halothane. There were no significant changes in the plasma concentrations of sodium or chloride exceptin the halothane-nitrous oxide-oxygen series.


The effect of modified electroconvulsive therapy on plasama potassium concentration. The influence of modified Type 11 electroconvulsive therapy (ECT) on plasma potasium was studied in 60 patients anaesthetized with a barbiturate and suxamethonium and the finding compared with a "control" group of patients having the same anaesthesia but not ECT. In the ECT series, plasma potassium concentration increased to a maximun 1 min after suxamethonium fasciculations and this increase occurred earlier and was more marked than that observed in the control group. It was also slightly shorter in duration, as was the comparable period of respiratory depression. These findings can be accounted for by the synchronous contraction of muscles containing blood with an increased potassium concentration following suxamethonium.


A comparison of chlormethiazole and diazepam as intravenous sedatives for fibre-endoscopic examination of the upper gastrointestinal tract. Chlormethiazole and diazepam as intravenous sedatives were compared in 75 patients undergoing fibre-endoscopic examination of the upper gastrointestinal tract. Diazepam was considered to offer greater reliability and ease of administration. Chlormethiazole wqs found to be a safe drug and did not encourage salivation. Local pain caused by chlormethiazole injection can be abolished by the use of lignocaine. Chlormethiazole may be useful in patients who are hypotensive and who require emergency endoscopy.


Pathology in the extradural space.

Pathology in the extradural space. The case histories are reported of one patient who developed evidence of extradural infection 16 days postpartum, and another who spontaneously developed an extradural haematoma. Several points of interest and concern raised by these case histories are discussed.


Potentiation of suxamethonium blockade by neostigmine in patients with atypical cholinesterase. This report describes the potentiation of a suxamethonium-induced (0.1 mg/kg) neuromuscular block in two  children with atypical serum cholinesterase activity, and compares  it with a control response demonstrated in a homozygote brother. In the atypical homozygote patients, suxamethonium produced a markedly prolonged neuromuscular block associaiated with partial desensitizatin as evidenced by tetanic fade and post-tetanic facilitation. The use of neostigmine 0.05 mg/kg for reversal was followed by a paradoxical potentiation of the block and a marked delay in recovery. It is suggested that in atypical homozygotes, the development of desensitization after suxamethonium does not necessarily imply that the block will be reversed with neostigmine.


The solubility of halothane in canine blood and tissues. In vitro measurements were made of the solubility of halothane (about 1%, carried in 5% carbon dioxide in air) in tissues taken from dogs, mostly Alsatians, and usually after about 8 hr anaesthesia with pentobarbitone and halothane. The mean Ostwald solubility coefficient lambda in atm- minus 1 at 37 degrees C, for seven to 21 animals, were: brain 6.03, gut 4.23, cardiac muscle 4.88, kidney 4.95, liver 6.64, skeletal muscle (psoas) 5.45. For the gracilis muscle solubilities up to 20 atm- minus 1 were obtained. Solubility in blood was shown to increase significantly with haematocrit and haemoglobin and to be significantly higher in blood from unanaesthetized than from anaesthetized animals. The best-estimate equations were lambda-2.38 + 0.042H for the unanaesthetized condition and lambda-1.69+0.049 H for the anaesthetized condition, where H is haematocrit %. Combining the present results with those for other species showed that the solubility of halothane increased fairly systematically from blood to kidney to brain to liver, and from ox to man to dog to rabbit.


A new method for the measurement of carbon dioxide in the expired air. A new method for measuring the concentration of carbon dioxide in the expired air, based on the variation of the gas in water, is described. The sensitivity of the basic instrument is such that it is able to measure parts per million but is non-linear above 1% carbon dioxide. The construction of a modified instrument to produce a linear output between 0-10% carbon dioxide is described.


Anatomical factors in difficult direct laryngoscopy. The anatomical factors in difficult direct laryngoscopy have been assessed. Thirteen patients in whom direct laryngoscopy proved difficult and thirteen control patients, all with teeth, had lateral, postero-anterior and submento-vertical radiographs taken. Several measurements were made and compared. The most important factor determining the ease of examination was the posterior depth of the mandible. An increase in this measurement was thought to hinder displacement of the soft tissues by the laryngoscope blade. Other factors of importance were: an increase in the anterior depth of the mandible; a reduction in the distance between the occiput and the spinous process of C1, and to a lesser extent the C1-C2 interspinous gap; and reduced mobility of the mandible associated with temporo-mandibular joint arthritis or trismus.


A return to trichloroethylene for obstetric anaesthesia. A study of 405 patients revealed that the substitution of 0.1% trichloroethylene for 0.1% methoxyflurane in a previously established technique of anaesthesia led to no remarkable changes in the incidence of postoperative nausea, vomiting or headache. There was, however, an increase in the incidence of awareness from 3.5% to 5.1%. There was no significant difference in the Apgar scores (totals or individual components) or in the materno-foetal acid-base gradients at delivery between the Group A elective Caesarean section patients in the two series. In view of these findings, and of the relative freedom from toxicity and the inexpensiveness of trichloroethylene, a more general re-introduction of the drug into anaesthetic practice is advocated. The study also served to demonstrate that, using the technique described, the duration of the interval from induction of anaesthesia to the initial incision into the myometrium was, at least up to 30 min, of no significant import to the well-being of the infant, but that the time elapsing between uterine incision and complete delivery was directly and significantly associated with neonatal asphyxia and clinically-apparent depression of the infant.


Postoperative hypoxaemia and oxygen therapy. Arterial blood and expired gas samples were taken from 20 patients before operation and on the first day after upper abdominal surgery. After operation the patients were studied breathing air and also breathing 35% oxygen from a venturi-type mask. Preoperative Pao2 with age was exaggerated by operation. Pao2 after operation was closely related to, and lower than, the preoperative value. The postoperative Pao2 during oxygen therapy correlated well with the postoperative Pao2 breathing air. Severely hypoxaemic patients show less improvement of oxygen tension during 35% oxygen therapy.